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Introduction to HIV

Introduction to HIV. LTC Rose Ressner Infectious Disease staff Walter Reed National Military Medical Center. Disclaimer.

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Introduction to HIV

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  1. Introduction to HIV LTC Rose Ressner Infectious Disease staff Walter Reed National Military Medical Center

  2. Disclaimer The views expressed in this presentation are those of the speaker and do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government

  3. Outline • Background and Epidemiology • Acute HIV Infection • HIV-2 • Diagnostics • Post-exposure prophylaxis (PEP)

  4. Background June 5, 1981: 5 cases of PCP in homosexual men from UCLA (MMWR)

  5. Background • 1982: • Term “AIDS” coined • First cases in women reported • First transfusion and vertically transmitted cases reported • 1983: • Isolation of a retrovirus from a patient with AIDS

  6. Background • Origin of HIV • Not completely understood • Phylogeneticstudies suggest that HIV evolved from a lentivirus, simian immunodeficiency virus (SIV) • HIV mainly targets CD4+ T lymphocytes

  7. Global summary of the AIDS epidemic  2012 Number of people living with HIV Total Adults Women Children (<15 years) Total Adults Children (<15 years) Total Adults Children (<15 years) 35.3 million [32.2 million – 38.8 million] 32.1 million [29.1 million – 35.3 million] 17.7 million [16.4 million – 19.3 million] 3.3 million [3.0 million – 3.7 million] 2.3 million [1.9 million – 2.7 million]2.0 million [1.7 million – 2.4 million] 260 000 [230 000 – 320 000] 1.6 million [1.4 million – 1.9 million]1.4 million [1.2 million – 1.7 million] 210 000 [190 000 – 250 000] People newly infected with HIV in 2012 AIDS deaths in 2012 www.who.int

  8. Regional HIV and AIDS statistics and features  2012 Adults and children living with HIV Adults and children newly infected with HIV Adult prevalence (15‒49) [%] Adult & child deaths due to AIDS Sub-Saharan Africa 25.0 million [23.5 million – 26.6 million] 1.6 million [1.4 million – 1.8 million] 4.7% [4.4% – 5.0%] 1.2 million [1.1 million – 1.3 million] Middle East and North Africa 260 000 [200 000 – 380 000] 32 000 [22 000 – 47 000] 0.1% [0.1% – 0.2%] 17 000 [12 000 – 26 000] South and South-East Asia 3.9 million [2.9 million – 5.2 million] 270 000 [160 000 – 440 000] 0.3% [0.2% – 0.4%] 220 000 [150 000 – 310 000] East Asia 880 000 [650 000 – 1.2 million] 81 000 [34 000 – 160 000] <0.1% [<0.1% – 0.1%] 41 000 [25 000 – 64 000] Latin America 1.5 million [1.2 million – 1.9 million] 86 000 [57 000 – 150 000] 0.4% [0.3% – 0.5%] 52 000 [35 000 – 75 000] Caribbean 250 000 [220 000 – 280 000] 12 000 [9400 – 14 000] 1.0% [0.9% – 1.1%] 11 000 [9400 – 14 000] Eastern Europe and Central Asia 1.3 million [1.0 million – 1.7 million] 130 000 [89 000 – 190 000] 0.7% [0.6% – 1.0%] 91 000 [66 000 – 120 000] Western and Central Europe 860 000 [800 000 – 930 000] 29 000 [25 000 – 35 000] 0.2% [0.2% – 0.2%] 7600 [6900 – 8300] North America 1.3 million [980 000 – 1.9 million] 48 000 [15 000 – 100 000] 0.5% [0.4% – 0.8%] 20 000 [16 000 – 27 000] Oceania 51 000 [43 000 – 59 000] 2100 [1500 – 2700] 0.2% [0.2% – 0.3%] 1200 [<1000 – 1800] TOTAL 35.3 million [32.2 million – 38.8 million] 2.3 million [1.9 million – 2.7 million] 0.8% [0.7% - 0.9%] 1.6 million [1.4 million – 1.9 million] The ranges around the estimates in this table define the boundaries within which the actual numbers lie, based on the best available information. www.who.int

  9. Adults and children estimated to be living with HIV  2012 Eastern Europe & Central Asia 1.3 million [1.0 million – 1.7 million] Western & Central Europe 860 000 [800 000 – 930 000] North America 1.3 million [980 000 – 1.9 million] East Asia 880 000 [650 000 – 1.2 million] Middle East & North Africa 260 000 [200 000 – 380 000] Caribbean 250 000 [220 000 – 280 000] South & South-East Asia 3.9 million [2.9 million – 5.2 million] Sub-Saharan Africa 25.0 million [23.5 million – 26.6 million] Latin America 1.5 million [1.2 million – 1.9 million] Oceania 51 000 [43 000 – 59 000] Total: 35.3 million [32.2 million – 38.8 million] www.who.int

  10. Estimated number of adults and children newly infected with HIV  2012 Eastern Europe & Central Asia 130 000 [89 000 – 190 000] Western & Central Europe 29 000 [25 000 – 35 000] North America 48 000 [15 000 – 100 000] East Asia 81 000 [34 000 – 160 000] Middle East & North Africa 32 000 [22 000 – 47 000] Caribbean 12 000 [9400 – 14 000] South & South-East Asia 270 000 [160 000 – 440 000] Sub-Saharan Africa 1.6 million [1.4 million – 1.8 million] Latin America 86 000 [57 000 – 150 000] Oceania 2100 [1500 – 2700] Total: 2.3 million [1.9 million – 2.7 million] www.who.int

  11. Estimated adult and child deaths from AIDS  2012 Eastern Europe & Central Asia 91 000 [66 000 – 120 000] Western & Central Europe 7600 [6900 – 8300] North America 20 000 [16 000 – 27 000] East Asia 41 000 [25 000 – 64 000] Middle East & North Africa 17 000 [12 000 – 26 000] Caribbean 11 000 [9400 – 14 000] South & South-East Asia 220 000 [150 000 – 310 000] Sub-Saharan Africa 1.2 million [1.1 million – 1.3 million] Latin America 52 000 [35 000 – 75 000] Oceania 1200 [<1000 – 1800] Total: 1.6 million [1.4 million – 1.9 million] www.who.int

  12. HIV prevalence among adults (15-49) % 2012 Adult HIV prevalence (%) www.who.int

  13. Transmission • Sexual contact (co-existing STI ↑ risk) • Blood and body fluid exposures • IV drug use • Mother to child • In utero • Delivery • Breast feeding

  14. Transmission Performed on a male UpToDate Risk of perinatalHIV transmission 15-45% (without ART)

  15. Acute HIV • Typically occurs 2-12 weeks after infection • Symptoms can be nonspecific, and last for several weeks (usually at least 7-10 days) • Many are asymptomatic • High risk for transmitting HIV to others • Very high viral load • Unaware of disease • Diagnosis: • High index of suspicion + HIV RNA (viral load) • Viral load usually in the 100,000+ range • Antibody testing generally not useful as seroconversion may not have occurred yet (window period)

  16. Acute HIV

  17. Acute HIV www.hivguidelines.org

  18. HIV-2 • Serologic evidence in 1985 in Senegal • Isolated in 1986 from a Cape Verdean patient • Originally transmitted from West African Sooty mangabeys to humans • Endemic in West Africa • Less pathogenic than HIV-1 • Longer asymptomatic stage of infection • Slower decline CD4 count • Lower levels of plasma viremia in chronically-infected patients

  19. HIV-2 • Diagnosis • Most EIA (screening) test for HIV-1 and HIV-2 • Confirmatory western blot testing may be indeterminate • gag (p55, p24, or p17) plus pol (p66, p51, or p32) bands • NOenv (gp160, gp120, or gp41) bands • HIV-2 specific western blots and viral load assays are available • Contact WRAIR - MHRP (Dr. Sheila Peel’s lab) • Treatment can differ from HIV-1 due to intrinsic resistance to some ART drugs

  20. Diagnostics • Antibody testing: • HIV 1-2 ELISA with confirmatory Western blot • Rapid HIV testing (confirmatory testing required) • OraQuick (tests saliva sample) – 20 mins • Uni-Gold Recombingen – 10-12 mins • p24 antigen testing • HIV RNA

  21. Detection of HIV by Diagnostic Tests Symptoms p24 Antigen HIV RNA HIV EIA* Western blot 0 1 2 3 4 5 6 7 8 9 10 Weeks Since Infection *3rd generation, IgM-sensitive EIA *2nd generation EIA *viral lysate EIA Fiebiget al, AIDS 2003;17(13):1871-9 4th generation combines EIA with p24 antigen detection

  22. HIV PEP • Resource: Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposure to Human Immunodeficiency Virus and Recommendations for Post-Exposure Prophylaxis. Infection Control and Hospital Epidemiology 2013;34 (9): 875-892.

  23. USASOC HIV PEP Protocol Nov 2013

  24. Percutaneous injury (needlestick, cut) OR Contact of mucous membrane or nonintact skin WITH: Blood Tissue Other body fluids that are potentially infectious(cerebrospinal, synovial, pleural, pericardial, peritoneal, or amniotic fluids; semen or vaginal secretions) Occupational Risk Exposures www.aidsetc.org

  25. Feces Nasal Secretions Saliva Sputum Sweat Tears Urine Vomitus NOT Considered Infectious for HIV UnlessVisibly Bloody www.aidsetc.org

  26. Approximate Risk of Occupational Transmission of HIV • Following percutaneous exposure: 0.3% • Following mucous membrane exposure: 0.09% • Risk following nonintact skin exposure: <0.09% • Risk following exposure to fluids or tissues other than HIV-infected blood estimated to be “considerably lower” than for blood exposure www.aidsetc.org

  27. Factors Associated with ↑Risk • Visible contamination of device (such as needle) with patient’s blood • Needle having been placed directly into vein or artery • Hollow-bore (vs solid) needle • Deep injury • Source patient with terminal illness • High viral load* * Risk of transmission via occupational exposure to a source patient with undetectable viral load is thought to be very low but not impossible; PEP should be offered. www.aidsetc.org

  28. PEP labs • Exposed patient • HBV surface antibody (HBsAb) • HBV surface antigen (HBsAg) • HCV antibody • HIV antibody (EIA/ELISA) • (AST/ALT, RPR) • Source patient • Rapid HIV • HBsAg • HCV antibody • HIV antibody • (RPR)

  29. PEP • Preferred PEP regimen: • Raltegravir 400 mg BID + TDF/FTC (Truvada) 1 pill daily • PEP should be taken for 28 days • Consult with ID, especially for: • Pregnant or lactating • Delayed exposure report (ie, >72 hours) • Unknown source • Known or suspected ART resistance in source patient • Toxicity of the initial PEP regimen • Co-morbid conditions in the exposed person • Possible HIV-2 exposure

  30. PEP • Follow-up testing • HIV testing at baseline, 6 weeks, 12 weeks, and 6 months after exposure • If 4th-generation p24 Ag/HIV Ab test is used: HIV testing at baseline, 6 weeks, 12 weeks, and 4 months after exposure

  31. AFRICOM MOD1 Nov 2013

  32. Further resources • Managing exposure to hepatitis B and C • Hep B (MMWR 20 Dec 2013; Vol 62, No. 10) • Hep C (MMWR 2001;50(RR-11); online at http://www.cdc.gov/mmwr/PDF/rr/rr5011.pdf • Non-occupational HIV exposure • July 2013 NYHD guidelines (www.hivguidelines.org) • AKO ID consult: id.consult@us.army.mil • National HIV/AIDS Clinicians’ Postexposure Prophylaxis Hotline (PEPline) • 24-hour telephone consultationservice: 888-448-4911

  33. ART costs (DoD) 30 day supply • -Atripla: $1055.55 • -Complera: $1122.93 • -Stribild: $1753.44 • -FTC/TDF/ATV/rit: $1336.34 • -FTC/TDF/DRV/rit: $1317.10 • -FTC/TDF/Raltegravir: $1335.76 • -FTC/TDF/Dolutegravir: $1583.56

  34. QUESTIONS?? AIDS Orphans in Kenya

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